“preventing adverse drug events and harm” · steven meisel, pharm.d., director of patient...
TRANSCRIPT
“Preventing Adverse Drug Events
and Harm”
Frank Federico, RPh, IHI Executive Director
Steve Meisel, PharmD, IHI Faculty
March 27th,2012
12:00 - 1:00pm ET
Beth O’Donnell, MPH
Beth O’Donnell, MPH, Institute for Healthcare Improvement
(IHI), is responsible for managing and coordinating strategic
partnerships. Ms. O’Donnell received her undergraduate degree
at St. Lawrence University and her graduate degree from The
Dartmouth Institute for Health Policy and Clinical Practice. She
joined IHI in August.
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Overall Objectives
Participants will be able to:
• Identify opportunities to decrease Adverse
Drug Events (ADEs)
• Describe three process changes needed
to reduce ADEs
• Discuss what measures are needed to
determine the impact of interventions
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Frank Federico, RPh
Frank Federico, RPh, Executive Director, Strategic
Partners, Institute for Healthcare Improvement (IHI), works in
the areas of patient safety, application of reliability principles
in health care, preventing surgical complications, and
improving perinatal care. He is faculty for the IHI Patient
Safety Executive Training Program and co-chaired a number
of Patient Safety Collaboratives. Prior to joining IHI, Mr.
Federico was the Program Director of the Office Practice
Evaluation Program and a Loss Prevention/Patient Safety
Specialist at Risk Management Foundation of the Harvard
Affiliated Institutions, and Director of Pharmacy at Children's
Hospital, Boston. He has authored numerous patient safety
articles, co-authored a book chapter in Achieving Safe and
Reliable Healthcare: Strategies and Solutions, and is an
Executive Producer of "First, Do No Harm, Part 2: Taking the
Lead." Mr. Federico serves as Vice Chair of the National
Coordinating Council for Medication Error Reporting and
Prevention (NCC-MERP). He coaches teams and lectures
extensively, nationally and internationally, on patient safety.
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Steven Meisel, Pharm.D.
Steven Meisel, Pharm.D., Director of Patient Safety
for Fairview Health Services, an integrated health
system based in Minneapolis, Minnesota. In this role
he is responsible for all aspects of patient safety
improvement, as well as related measurement,
reporting, educational and cultural initiatives. Dr.
Meisel has served as faculty for the Institute for
Healthcare Improvement safety since 1997. Dr.
Meisel is the recipient of numerous awards, including
the 2005 University Health-System Consortium
Excellence in Quality and Safety Award. He is the
author of several publications.
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Session Agenda
• Homework – What did you learn?
• Health Information Technology & Medical
Education
o Preventing ADEs Using IT
o Improving Quality of Drug Ordering Using CPOE
o Alerting
o Barcoding
o IV Medication Safety
o HIT
• Looking Back on Your Journey
• Q&A
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Review of Homework
• Review your system related to medication
reconciliation and health literacy.
• Examine standardized processes around
medication reconciliation. If in place, are
processes used as designed?
• Identify one change you will test to improve
either medication reconciliation and/or health
literacy.
• What outcome and process measures are you
using, or will use?
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Tejal Gandhi, M.D., M.P.H.
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Tejel Gandhi, M.D., M.P.H., is a board certified internist
and Associate Professor of Medicine at Harvard Medical
School. She received her MD and MPH from Harvard
Medical School and the Harvard School of Public Health,
and trained at Duke University Medical Center. Her
undergraduate training at Cornell University was in
biochemistry.
Dr. Gandhi’s research interests focus on patient safety
and reducing error using information systems. She won
the 2009 John Eisenberg award for her contributions to
understanding the epidemiology and possible prevention
strategies for medical errors in the outpatient setting. Dr.
Gandhi was the Executive Director of Quality and Safety
at Brigham and Women’s Hospital for 10 years, and in
that role, she worked to redesign systems to reduce
medical errors and improve quality. Currently, Dr. Gandhi
is Chief Quality and Safety Officer at Partners Healthcare.
In this role, she is helping to lead the efforts to
standardize and implement patient safety best practices
across the system.
Tejal Gandhi, M.D., M.P.H.
Chief Quality and Safety Officer, Partners Healthcare
Associate Professor of Medicine
Harvard Medical School
Health Information Technology and Medication Safety
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Objectives
• Describe HIT innovations and their impact
on medication safety
• Highlight strategies for success when
designing HIT initiatives
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Handwriting Example
15
16
Medication Safety
• The typical hospital medication process has
several steps: ─ Ordering- MD orders medication
─ Transcribing- nurse copies order onto a paper medication
administration record (MAR)
─ Dispensing- pharmacy sends medication to the floor
─ Administering- nurse gives medication to patient and documents
this on the MAR
• Medication errors in hospitals are common and
can have serious consequences ─ Errors can occur at any stage
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MD
Pharmacist
Medication on
Wards
RN Patient
Medication
Admin Record
Dispensing
Transcription
Med Orders
Administration
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MD
Pharmacist
Medication on
Wards
RN Patient
Medication
Admin Record
Dispensing
Transcription
Med Orders
Administration
Ordering
Errors (49%)
Transcription
Errors (11%) Dispensing
Errors (14%)
Administration
Errors (26%)
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Main Strategies for Preventing
Errors Using IT
• Tools to improve communication
• Making knowledge more readily accessible
• Requiring key pieces of information
• Assisting with calculations
• Performing checks in real time
• Assisting with monitoring
• Providing decision support Bates and Gawande, NEJM 2003
20
Potential IT Solutions
• Computerized physician order entry
(CPOE) tackles ordering errors
─Computerized writing of orders
─55% reduction in serious med errors
• Barcoding, electronic medication
administration records (eMAR), and smart
pumps can tackle transcription, dispensing
and administration errors
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Improving the Quality of Drug Ordering
with CPOE
• Streamline, structure process ─ Doses from menus
─ Decreased transcription
─ Complete orders required
• Give information at the time needed ─ Show relevant laboratories
─ Guidelines
─ Guided dose algorithms
• Perform checks in background Drug-allergy Dose ceiling
Drug-lab Drug-patient
Drug-drug
Allergy to Medication
22
High Chemotherapy Dose Warning
23
Impact of CPOE on Medication Errors
• CPOE reduced medication errors by 80%
• CPOE reduced serious medication errors
by 55%
24
Bates DW et al. JAMA 1998
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Overriding of Alerts
• Studies have shown that MDs override clinical decision support
alerts a large percent of the time
─ 88% of inpatient DDI alerts overridden (Payne et al. Proc AMIA
2002)
─ 83% of inpatient drug-allergy alerts (Abookire et al. Proc AMIA
2000)
─ 89% of outpatient high severity DDI alerts and 91% of outpatient
drug-allergy alerts (Weingart et al. Arch Intern Med 2003)
• Over alerting has led to major boycotts of CPOE systems (e.g.
Cedars Sinai)
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Potential Strategies to Improve
Alerting
• Creation of streamlined knowledge bases
─ Only essential content
─ Balance between sensitivity and specificity
• Tiering of alerts is also a possibility
─ Hard stop
─ Interruptive
─ Non-interruptive
• Minimizing interruptions
• Did this in EMR
─ 67% of alerts accepted vs. 20% from most studies
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Alerting Summary
• Streamlined knowledge bases and tiered alerting have higher
acceptance rates
─ Especially for very high risk alerts
• What is our ideal acceptance rate?? Sensitivity/specificity?
Best way to display?
• More work needs to be done to maximize the clinical benefits
• Sharing of streamlined knowledge should be widespread
─ No need to reinvent the wheel
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Epidemiology of Dispensing Errors
• Dispensing errors are relatively common in hospital pharmacies
because of the high volume of medications dispensed
─ 44,000 errors/year in a 735-bed hospital (6 million doses/yr)
• Many dispensing errors have potential for harm
─ More than 9500 errors with potential to harm patients occur
per year in a 735-bed hospital
─ Only 1/3 of these serious errors intercepted prior to
administration
Cina, Gandhi, Churchill, Fanikos, McCrea, Mitton, Rothschild, Featherstone, Keohane, Bates, Poon.
Jt Comm J of Qual & Safety. Jt Comm J of Quality and Safety, Feb 2006
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Pharmacy Barcoding
• Pharmacy technicians use barcode
scanning to verify that the drug they are
dispensing matches the physicians’ orders
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Dispensing Errors and Potential ADEs: Measurement/Evaluation
0.19%
0.61%
0.88%
0.07%
0.00%
0.20%
0.40%
0.60%
0.80%
1.00%
Dispensing Error Rate Potential ADE Rate
Before Period (115164
doses observed)
After Period (253984
doses observed)
* p<0.0001 (Chi-squared test)
Poon, Cina, Churchill, Featherstone, Rothschild, Keohane, Bates, Gandhi. Annals of Internal Medicine 2006.
31%
reduction*
63%
reduction*
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Effect of Barcode Technology on
Target Potential ADEs
0.06%
0.08%
0.04%
0.03%
0.04%
0.00%0.00%
0.02%
0.04%
0.06%
0.08%
0.10%
0.12%
Wrong Medication Wrong Dose/Strength Wrong Dosage Form
Before Period (115164 doses observed)
After Period (253984 doses observed)
* p<0.001 (Chi-squared test)
53%
reduction
*
100%
reduction
*
58%
reduction
*
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Projected Impact at
Brigham & Women’s Hospital
• As we speak, the barcode pharmacy system is
preventing per year:
─ >13,500 medication dispensing errors (31%
reduction)
─ >6,000 errors with potential for harm (63% reduction)
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Benefits of Barcode Technology in
the Pharmacy
• Medical costs saved through adverse drug event
reduction, per year
• Increased on-time medication availability on nursing
units
• Improved inventory control
• Formal cost benefit analysis showed break-even within
first year after go-live
─ 5-year cumulative net benefit = $3.3M
Maviglia, S et al. Archives of Internal Medicine 2007
34
EMAR/Barcoding
• After CPOE and pharmacy barcoding, most
common error type at BWH was administration
errors
─Based on safety reporting
─Research studies from other groups
highlighted the frequency of these kinds of
errors
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Barcode/EMAR at the Bedside
• Orders flow electronically from CPOE to an electronic medication
administration record (eMAR)
─ Eliminates transcription entirely
─ Nurses have laptops with eMAR and use this to track what
medications need to be given (administered)
• Nurses use barcode scanning of the medication and the patient to
verify that the drug they are administering matches the physicians’
orders
─ Right drug, right patient, right dose, right time
─ eMAR alerts if any of these is incorrect
─ Potentially reduces administration errors
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Intervention Design/Implementation
• 2D Imagers ─ Both 1 and 2 dimensional bar codes
─ Wireless blue tooth compatible
• Computer Hardware ─ Full size laptop
─ Complete desktop functionality
─ Mobile carts
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Scheduling of Medications
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Wrong Medication Alert
39
Wrong Patient Alert
40
Impact of Barcode Scanning
Technology on Administration Errors
No Barcode
Scanning
(n=6712)
Barcode
Scanning
(n=7314)
Relative Reduction
(p-value)
Medication
Administration Errors
11.5% 6.7% 41% (p<0.001)
Potential Adverse Drug
Events
3.1% 1.6% 50.8% (p<0.001)
Poon et al. NEJM 2010
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Impact of EMAR on Nurse
Satisfaction
• Pre and post surveys
• Main Results: Nurses feel medication administration is
safer and more efficient after implementation of barcode
technology
Hurley, A et al. Journal of Nursing Administration 2007
42
Impact on Nurse Workflow
• 232 2-hour observation sessions before and after
barcode/eMAR implementation
• Primary Result: Proportion of time spent on medication
administration did not change after barcode/eMAR
implementation
• Secondary Result: Proportion of time spent in presence
of patient increased
Poon, et al. Journal of Nursing Administration 2008
43
Barcode Summary
• Barcode technology significantly reduces dispensing,
transcription, and administration errors
• Benefits of the technology outweigh its costs in the
hospital pharmacy
• A well-designed and fully-supported system did not
increase the proportion of time nurses spend on
medication administration
• The technology does not appear to compromise the
amount of time nurses spend with patients.
• Key is involvement of end users from the beginning in
design, hardware selection, and piloting
44
IV Medication Safety
• Several studies show that IV medications are
responsible for 54-61% of the most serious and
life threatening potential adverse drug events.
• Almost all “high risk” drugs (heparin, insulin,
morphine, potassium chloride) are administered
via the IV route.
45
Smart Pumps and Medication Safety
• Barcoding helps ensure right drug, time, etc.
• However, for IV medications, the biggest error involves programming the infusion pump ─Manual nursing step
─Barcoding does not address this (yet…) Work in progress to automatically program pumps
via wireless communication or barcode scanning
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Features of the “Smart” Pumps
• “Smart” pumps share safety features of older pumps
• “Smart” pumps also equipped with a drug library ─ Provide dose and rate limits on
commonly used medications
─ Provide users with overdose and under dose alerts
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Case Examples:
Decision Support Near Miss Intercepts
• Dopamine
─ entered at 70 mcg/kg/min instead of 7
• Epinephrine
─ entered at 32 mcg/min instead of 2
• Heparin
─ entered [ ] of 5 units/250 cc rather than
25,000/250 cc
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Summary: Impact on Serious
Medication Errors
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Outpatient Adverse Drug Events
25% (162/661) primary care patients had
an adverse drug event (ADE) 13% (24) serious
11% (20) preventable
28% (51) ameliorable
6% (n=13) both serious and preventable or ameliorable
Gandhi TK, et al. NEJM April 2003.
50
Outpatient Prescribing Errors
1879 prescriptions reviewed
─ Medication errors 143 (7.6%)
Potential ADEs 62 (3%) – Life threatening 1 (2%)
– Serious 15 (24%)
– Significant 46 (74%)
51
Prevention
• More advanced computer prescribing
checks with decision support would have
prevented 95% of potential ADEs
─Majority of prevention from complete
prescriptions, drug-dose, and drug-frequency
checking
52
Eprescribing Impact
• One study of 15 providers before and after
implementation of eprescribing
─Error rates reduced from 42/100 prescriptions
to 6/100 prescriptions
Kaushal, R. et al. JGIM 2010
53
Impact on multispecialty group practice
• Pre-post study
• Prescription errors decreased from 18% to 8%
• Largest reductions:
─ Illegibility
─ Inappropriate abbreviations
─Missing information
• No reduction in errors with potential for harm (likely power issue)
Devine, E et al. JAMIA 2010
54
Medication Reconciliation
• Designed a tool to display patients home meds
electronically, pulled from EMR, prior discharge
summaries
• Residents use that to create Pre-admission
medication list and subsequent admission
orders
Schnipper, J. Arch Intern Med 2009
55
Intervention I: PAML Builder
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PAML Builder: Action on Admission
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Discharge Medication Ordering Screen
58
Patient Discharge Medication
Education
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Medication Reconciliation
• Demonstrated 55% reduction in medication
discrepancies with potential for harm
• Similar application built for post-discharge
medication reconciliation
─ Displays hospital discharge meds side by side with
EMR meds
─ Impact being studied
Schnipper, J. [unpub data]
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LMR Medication Reconciliation
Screen
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Key Elements for HIT Success
• Senior leadership support for IT resources and patient safety
─ Emphasize safety benefits/stories/data
• Clinical staff champions to support use of technology
─ Key to demonstrate/measure benefit
─ Key to involve clinical users in design process and get their
feedback
User groups
─ Key to understand workflow and speed
─ Key during rollouts to emphasize safety benefits
• Be ready to uncover unknown processes that have been supporting
the existing process
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Key Elements for HIT Success (cont.)
• Avoid over engineering functionality
─ Keep it Simple
─ Make it Easy to Do the Right Thing
• Implement well
─ 24/7 support and super-users
─ Training is most successful when clinicians teach clinicians
• Measure impact
─ Unintended consequences
• Continually seek user feedback for improvements
─ Electronic
─ Face-to-face
─ Override data
• The work never ends!
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HIT and Medication Safety Summary
• Non-technology and technology solutions are both important for
improving medication safety
─ Creating a culture of safety and ensuring action based on events
identified is critical
• Technology can provide the high reliability infrastructure to reduce
human error
• HIT can have large impact on physician decision making and
improved communication between systems, providers and patients
• Studying the impact of these interventions is essential
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Looking Back…
• Kick Off Session, Jan. 17th: Introduction to Contributing
Factors for ADEs
• Session 2, Jan. 31st: Improving Narcotics & Opiate
Management
• Session 3, Feb. 14th: Improving Insulin Management
• Session 4, Feb. 28th: Improving Anticoagulation
Management
• Session 5, March 13th: Medication Reconciliation & Health
Literacy
• Session 6, March 27th: Technology Solutions
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Follow Up Items
• Listserv will remain active, so please
continue to share and ask questions!
• Along with the recording, the follow up
email will contain a Continuing Education
Handbook to help guide you through the
CEU process. It will also contain a
program Evaluation.
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Thank You!